EXAM-LATEST UPDATE 2025| COMPLETE QUESTIONS
WITH CORRECT DETAILED AND VERIFIED ANSWERS |
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A nurse is caring for a client who's receiving mechanical ventilation when the
low-pressure alarm sounds. which of the following situations should the nurse
recognize as a possible cause of the alarm?
A.) Excess secretions
B.) Kinks in the tubing
C.) Artificial airway cuff leak
D.) Biting on the endotracheal tube - (answers)artificial airway cuff leak
rationale:
An artificial airway cuff leak interferes with oxygenation and causes the low-
pressure alarm to sound.
a nurse is providing discharge teaching to a client who has a temporary
tracheostomy. which of the following statements by the client indicates an
understanding of the teaching?
A.) "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to
cleanse around my stoma."
B.) "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube
to absorb drainage."
C.) "I should remove the old twill ties after the new ties are in place."
,D.) "I should apply suction while inserting the catheter into my tracheostomy
tube." - (answers)"I should remove the old twill ties after the new ties are in place."
rationale:
As a safety measure, the nurse should teach the client to wait until the new ties are
in place to remove the old ties. This practice can prevent accidental decannulation.
a nurse is caring for 4 clients. which of the following clients is at greatest risk for a
pulmonary embolism?
A.) A client who is 48 hr postoperative following a total hip arthroplasty
B.) A client who is 8 hr postoperative following an open surgical appendectomy
C.) A client who is 2 hr postoperative following an open reduction external
fixation of the right radius
D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy -
(answers)A client who is 48 hr postoperative following a total hip arthroplasty
rationale:
The nurse should identify that a client who has undergone a total hip arthroplasty
surgery is at greatest risk for a pulmonary embolus because of decreased mobility
of the affected extremity and an increased amount of blood clots forming in the
veins of the thigh following hip surgery. Deep-vein thromboses are most likely to
occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce
the risk by applying sequential compression devices or antiembolic stockings and
by administering anticoagulant medications.
a nurse is caring for a newly admitted client who has emphysema. the nurse should
place the client in which of the following positions to promote effective breathing?
,A.) Lateral position with a pillow at the back and over the chest to support the arm
B.) High-Fowler's position with the arms supported on the overbed table
C.) Semi-Fowler's position with pillows supporting both arms
D.) Supine position with the head of the bed elevated to 15° - (answers)High-
Fowler's position with the arms supported on the overbed table
rationale:
The nurse should place the client in a position that allows for greater expansion of
the chest, such as sitting upright and leaning slightly forward while supporting both
arms with pillows for comfort on the overbed table.
a nurse is caring for a client who has asthma and is receiving albuterol. for which
of the following adverse effects should the nurse monitor the client?
A.) Hyperkalemia
B.) Dyspnea
C.) Tachycardia
D.) Candidiasis - (answers)Tachycardia
rationale:
The nurse should monitor the client for tachycardia, which is a common adverse
effect of this medication, especially if the client uses albuterol on a regular basis.
a nurse is preparing a client for discharge following a bronchoscopy with the use of
moderate sedation. the nurse should identify that which of the following
assessments if the priority?
A.) presence of gag reflex
, B.) pain level rating using 0 to 10 scale
C.) hydration status
D.) appearance of the IV insertion site - (answers)presence of gag reflex
rationale:
The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore,
the priority assessment by the nurse is to determine the return of the gag reflex.
a nurse is assessing a client who has lung cancer. which of the following
manifestations should the nurse expect?
A.) Blood-tinged sputum
B.) Decreased tactile fremitus
C.) Resonance with percussion
D.) Peripheral edema - (answers)blood-tinged sputum
rationale:
The nurse should expect blood-tinged sputum secondary to bleeding from the
tumor.
a nurse working in an ED is caring for a client following an acute chest trauma.
which of the following findings should indicate to the nurse that the client is
possibly experiencing a tension pneumothorax?
A.) Collapsed neck veins on the affected side
B.) Collapsed neck veins on the unaffected side
C.) Tracheal deviation to the affected side